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Get Optumrx 104-0006 2013-2025
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How to fill out the OPTUMRx 104-0006 online
The OPTUMRx 104-0006 form is used to order a new mail service prescription via fax from a prescribing physician's office. This guide provides a comprehensive, step-by-step approach to completing this form online to ensure efficient and accurate submission.
Follow the steps to successfully complete the OPTUMRx 104-0006 online.
- Click the 'Get Form' button to obtain the form and open it in your editing program.
- In section 1, the member must fill out their personal information, including their Member ID Number, Last Name, First Name, MI, Delivery Address, City, State, ZIP code, Date of Birth, Gender, Email, and Phone Number. Be sure to list any medication allergies and health conditions as well as any over-the-counter or herbal medications taken regularly.
- In section 2, the physician needs to complete their information including the Prescribing Physician Name, Patient Name, and contact details such as Phone and Fax Numbers. They should also include the patient's Date of Birth and either enter the prescription details or attach the office prescription to the form.
- The physician must also fill in the Physician Street Address along with the City, State, and ZIP code. They should provide their NPI and DEA numbers.
- In the prescription details section, the physician should indicate the number of refills desired and whether to dispense as written. This section requires the physician's signature along with the date.
- Once the order form is fully completed, the physician should fax the document to OptumRx at the provided number, 1-800-491-7997.
- After faxing the order form, users can save any changes, download a copy, print the completed form for their records, or share it as necessary.
Complete your OPTUMRx 104-0006 form online today for a seamless prescription ordering experience.
To effectively file an appeal with OptumRx, begin by collecting all necessary documentation relevant to your case. Then, complete the appeal form provided on their website, ensuring that all details are accurately filled. After submission, expect a timely review to address your needs related to OPTUMRx 104-0006.
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